**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with facility staff including Transport Aide/Driver #1, the facility failed to ensure the lift gate/platform was in the elevated position before unloading a resident from the back of the facility van for 1 of 3 residents sampled for accidents (Resident #1). On 10/24/24 Transport Aide Driver #1 pushed Resident #1 backwards out of the van and he fell approximately 17 and ½ inches out of the transport van to a lift platform that was located on the ground. Resident #1 fell out of his wheelchair and landed on his left side with half of his body on the lift platform and the other half of his body on the asphalt, and he struck his head on the asphalt. Resident #1 was prescribed and administered a blood thinner twice a day which increases the risk of bleeding. After being assessed by the nurse, the resident was transported to the hospital via Emergency Medical Services (EMS) transport and at the hospital. Resident #1 was found to have sustained a subarachnoid hemorrhage (bleeding on the brain), a small laceration to the left side/back of his head, and a skin tear to his left elbow. There is a high likelihood of a serious adverse outcome or injury when the manufacturer's instructions for unloading residents from the transportation van are not followed. The findings included: Review of the manufacturer's operating instructions showed the following instructions for the use of the transportation van lift to unload a resident in a wheelchair. 1. Stand clear and press the unfold switch until the platform stops (reaches floor level of the vehicle - unfold fully). 2. Load passenger onto platform from floor level of the vehicle and lock wheelchair brakes. Notice: Passenger must be positioned fully inside yellow boundaries, roll stop must be UP, and roll stop latch must be engaged. 3. Press the DOWN switch until the entire platform reaches ground level and the roll stop unfolds fully (ramp position). 4. Unlock wheelchair brakes and unload passenger from platform. Resident #1 was admitted to the facility on [DATE]. The resident's diagnoses included in part a history of vascular dementia, chronic atrial fibrillation, chronic muscle weakness, abnormal gait, and chronic lumber pain. Resident #1's annual Minimum Data Assessment, dated 8/7/24, coded the resident as moderate cognitive impairment. The resident was coded to use a wheelchair for ambulation, and as needing substantial to maximum assistance to wheel at least 150 feet. Record review of Transportation Aide/Driver #1's personnel file showed she had completed initial transportation web classes and return demonstrations when using the lift. Further review showed annual transportation training review with the most recent training being completed on 10/17/24. The training included web-based courses which consisted of driving basics, defensive driving, how to prepare a resident for transport, and a return demonstration of using the lift to load and unload a resident checklist. Review of physician orders showed Resident #1 had an order dated 8/23/24 for apixaban (a blood thinner) 5 milligrams, take one tablet twice daily. Review of the October 2024 Medication Administration Record showed Resident #1 he was administered the apixaban twice daily including the a dose on the morning of 10/24/24. There had been no documented dose omissions for October 2024. Review of a statement signed by Transportation Aide/Driver #1 dated 10/24/24 read in part, I unsecured Resident #1 and removed his seatbelt and unlocked his brakes. I leaned over so that I could push his wheelchair back onto the lift. I didn't realize that the lift was still on the ground, so his wheelchair fell, landed in a sitting position on the lift, but then the wheelchair fell over backwards. When the wheelchair fell over backwards, he fell backwards out of the wheelchair. I jumped out of the van to see that he was conscious. The statement continued to say I ran to the door to inform staff I needed help and returned to Resident #1's side. I did not see anyone anywhere outside when he fell as I looked around to see if there was anyone outside that could help me. An interview was conducted by phone with Transportation Aide/Driver #1 on 12/11/24 at 11:38 AM. She stated she had worked at the facility for 3 years as a Social Service Assistant/Transportation Aide/Driver fill-in. Transportation Aide/Driver #1 said she had been trained on how to transport residents by the facility Director of Nursing (DON) who was the acting Staff Development Coordinator at that time. Transportation Aide/Driver #1 also said she completed her annual review on 10/17/24. Transportation Aide/Driver #1 confirmed how to use the facility van lift was part of that training and she felt very comfortable transporting residents to their appointments. Transportation Aide/Driver #1 said she would fill in for Transportation Aide/Driver #2 who normally drove the transport van. Transportation Aide/Driver #1 said on 10/24/24, the DON asked her to transport two residents to and from their appointments. Transportation Aide/Driver #1 said that when she returned to the facility, she opened up the back door of the transport van and moved the lift from its stowed position. Transportation Aide/Driver #1 said she unsecured the first resident, moved that resident onto the lift, used the lift control to lower the resident, and then rolled the resident into the facility. Transportation Aide/Driver #1 then said she returned to the van and stepped into the van through the side door entrance, unsecured Resident #1 by unhooking the straps, disengaging his wheelchair brakes, and began pushing him backwards out of the van to where the lift should have been. She said Resident #1's wheelchair rolled backwards out of the van and landed about 2 feet onto the lift that was still at ground level. She stated the next thing she knew Resident #1 was lying on his left side, completely out of the wheelchair, halfway onto the asphalt and half on the lift with his wheelchair off to the side of him. She added she couldn't remember exactly if Resident #1 flipped over backwards in his wheelchair before he landed or if he dropped 2 feet and then fell out of the wheelchair because, It all happened so quickly. Transportation Aide/Driver #1 said she knew immediately that she had forgotten to raise the lift back up and it was still at the ground level when she attempted to unload him from the van. Transportation Aide/Driver #1 said she knew she was supposed to check the lift was in the right position prior to moving the second resident. She said she didn't know why she didn't check the lift and that she must have had her mind on something else. The transportation aide/driver went to the front door of the facility to get assistance. Transportation Aide/Driver #1 said both Nursing Assistant (NA) #1 and NA #2 heard her banging on the front door and came to help. She said one of them, couldn't remember which one, ran to get Nurse #1 who also responded quickly. Transportation Aide/Driver #1 thought she may have moved Resident #1's wheelchair out of the way but wasn't sure. An interview was conducted with NA #2 on 12/11/24 at 11:25 AM. She said during the afternoon on 10/24/24, unsure of the time, she heard someone banging on the front door. She stated both her and NA #1 responded to the banging on the door. She said when she saw Resident #1 on the ground, she went out to help while NA #1 went to find a nurse. She stated Resident #1 was partially on the blacktop and half on the lift. She said she may have moved the wheelchair out of the way but could not remember if she did or if Transportation Aide/Driver #1 did. NA #2 remarked she noticed a skin tear on the left side of his head and one on his left arm. She explained neither area was bleeding very much, and she didn't notice any blood on the ground or lift. She said Resident #1 was lying on his left side and was conscious. NA #1 also stated Transportation Aide/Driver #1 told the NA#1 she had moved another resident off the van and forgot to raise the lift again before attempting to push Resident #1 off of the transport van. She further stated another staff member had called 911, unsure who, and EMS came to get him pretty quickly and transported him to the hospital for assessment. An interview was conducted with Nurse Aide (NA) #1 on 12/11/24 at 11:14 AM. NA #1 stated on 10/24/24 in the afternoon, unsure of time, she heard banging on the front door, came around the corner and saw it was Transportation Aide/Driver #1. She said both her and NA #2 responded to the banging on the door. She said when she saw Resident #1 on the ground, she immediately turned around to go find a nurse while NA #2 went outside to assist with Resident #1. NA #1 said when she went out to the van, she observed Resident #1 to be lying partially on the van lift and partially on the ground toward his left side. She did not remember seeing where his wheelchair was at that time. She commented she also noticed a small amount of blood on Resident #1's left arm and Resident #1 was conscious. She said she was unsure how Resident #1 fell at that time. Review of Resident #1's electronic medical record revealed an incident entry by Nurse #1 on 10/24/24 at 3:30 PM noting in part, Staff alerted nurse that resident was on the ground behind the van .skin tear to head and left elbow noted and occurred during transfer off of transportation van upon return from an appointment. Vital signs obtained. Skin tears are cleansed and dressed. Resident is being transported to the ER [emergency room] for evaluation by EMS [emergency medical services]. An interview was conducted with Nurse #1 on 12/11/24 at 12:12 PM. Nurse #1 said on the afternoon of 10/24/24, unsure of time, one of the NAs came to get her and told her that a resident was lying in the front parking lot. She said she grabbed her blood pressure monitor and pulse oximeter (a device used to measure the percentage of oxygen in the blood and pulse) and responded immediately. She said she found Resident #1 lying partially on the van lift and partially on the blacktop. She said he was conscious and was bleeding minimally from a wound on the left side/back of his head and from a small laceration on his left elbow. She further stated she performed an assessment, his vital signs were normal, and he was alert. She stated his hearing aid was not attached so communication was difficult, but he responded appropriately to her questions and pointed to his head when she asked if he had any pain. She explained she called 911 from her phone and the volunteer rescue squad arrived within a few minutes. Nurse #1 said she stayed on the ground with Resident #1 talking with him until the county EMS ambulance arrived and transported him to the hospital A review of Emergency Medical Services (EMS) record for showed the call was received by dispatch at 3:06 PM and EMS arrived at the facility on 10/24/24 at 3:33 PM. The record read Resident #1 was alert and wearing a cervical collar with abrasion noted to left arm and side/back of head. The record further read Patient fell backwards off an estimated 18-inch platform striking his head on the asphalt. No loss of consciousness per staff. Noted to be on a blood thinner. The record said Resident #1 remained alert during transport to the hospital for evaluation. A review of hospital records for Resident #1 for the hospitalization period of 10/24/24 through 10/28/24 revealed the following. Resident # 1 was seen in the emergency room (ER) on 10/24/24 following the fall out of a van. The physician noted the resident was alert and in no acute distress at the time of the physician's assessment. The physician's head to toe assessment of Resident #1 was normal except for a small laceration to the left side of head and another small laceration to the left elbow. The radiology report indicated that a computed tomography (CT) (a CT is a noninvasive medical imaging procedure that uses x-rays to create cross-sectional detailed pictures of the inside of the body) scan showed a small volume of acute subarachnoid hemorrhage along Resident #1's left frontal lobe. The report explained the volume of hemorrhage was not enough to cause pressure on the brain. Resident #1 was admitted to the hospital for observation. A follow-up CT dated 10/28/24 revealed the bleed had not grown in size and there were no new areas of concern identified. The physician discharge note dated 10/28/24 documented Resident #1's hospital course was unremarkable. Resident #1 was discharged from the hospital back to the facility on [DATE] with no new orders. An interview was conducted on 12/11/24 at 2:45 PM with the acting Director of Nursing (DON). She stated she was not in the role of DON when the incident occurred but was made aware of what happened the same day. She explained Transportation Aide/Driver #1 had completed the necessary training to safely load and unload residents from the facility van. The DON explained the Transportation Aide/Driver #1 stated she didn't know what happened other than she made a mistake and should have followed the steps on how to unload residents from the van laid out in her training. The DON stated Transportation Aide/Driver #1 no longer worked at the facility. An interview was conducted on 12/11/24 at 3:37 PM with the Administrator. She stated the facility immediately identified the incident on 10/24/24 as needing a plan of correction and it was implemented to ensure all residents were kept safe. She also said no other staff member will be allowed to operate the transport van lift if they have not fully completed the necessary training. During a follow-up call with the Administrator on 12/18/24 at 3:34 PM, she confirmed the measurement from the floor of the van to the ground was 17 and one half inches. On 12/11/24 at 4:03 PM, the Administrator was notified of immediate jeopardy. The facility implemented the following corrective action plan: 1.Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On October 24, 2024, at approximately 3:30 pm, 2 residents were returning to the facility from scheduled outside appointments via facility transportation service. Transportation Aide/Driver #1 pulled up outside the facility at the front entrance. Transportation Aide/Driver #1 unloaded Resident #2 from the lift that is located at the back doors of the van. Transportation Aide/Driver #1 then took Resident #2 inside the facility. When Transportation Aide/Driver #1 returned to the van, she did not raise the van lift to rear entrance of the van, she entered the van from the side door, and did not realize the van lift was still on the ground. Transportation Aide/Driver #1, while facing Resident #1 and the rear of the van, began to remove the wheelchair tie down straps and seatbelt from Resident #1's wheelchair, and unlocked the brakes of the wheelchair. The Transportation Aide/Driver #1 bent over forward and began to push Resident #1's wheelchair backward, towards the rear of the van. The Transportation Aide/Driver was unaware the lift remained on the ground. When Resident #1 reached the rear exit of the van, the wheelchair fell backward and resident #1 fell out of wheelchair onto the lift that was on the ground. As a result of the fall, Resident #1 hit his head on the base of the van lift. Resident #1 landed in a position where he was on his left side with his head and body in a fetal position with wheelchair on the left side, beside of resident #1. Transportation Aide/Driver #1 then jumped off the back of the van to check on the resident. Resident #1, who was alert and oriented, stated to her that his head hurt. Transportation Aide/Driver #1 ran 10 feet to the front door to call for help and returned to the resident's side. The Transportation Aide/Driver did not move Resident #1. Registered Nurse (RN) #1 responded to Resident #1 and assessed him. During RN #1's assessment, it was noted that he had a laceration (cut) to the back of his head with small amount of bleeding, and that his left arm was bleeding with superficial (on the surface of the skin) lacerations. RN #1 notified 911 and stayed with Resident #1 until local emergency services arrived. Emergency Medical Services (EMS) arrived at the facility after the local emergency services arrived and the resident was transported to the local hospital via EMS. The facility also notified the responsible party, and the facility physician. At the hospital, a Computed Tomography (CT) scan of Resident #1's head was completed that revealed a small volume left frontal subarachnoid hemorrhage, which is when there is bleeding in the space between the brain and the membrane that covers it. Resident #1 was admitted to the hospital on [DATE]. During his stay at the hospital, the small volume frontal subarachnoid hemorrhage resolved, and Resident #1 continued at baseline cognitive status. Resident #1 returned to the facility on October 28, 2024, and is a current resident in the facility. The resident did not have any long-term effects from his injury. Resident #1 was taking anticoagulant for a diagnosis of Atrial Fibrillation at the time of the fall. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On October 25, 2024, the Executive Director, the Regional Nurse Consultant, and the Director of Nursing completed an audit of all appointments in the last 90 days, and it was determined any resident could be at risk for this deficient practice if they were transported to an appointment on the facility van. Residents with a Brief Interview for Mental Status (BIMS) indicating mild cognitive loss to being cognitively intact were interviewed by the Social Worker and there were no concerns identified regarding the van ride or use of the lift. On October 25, 2024, skin sweeps were conducted on all current residents by the nurse managers with no issues. The Transportation Aide/Driver was interviewed by the Executive Director and the Human Resources Director on October 24, 2024, regarding any other falls during the onloading, off-loading or transport of any resident and there were no issues noted. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Transportation Aide/Driver #1 was immediately suspended on October 24, 2024, and an investigation was initiated. At the conclusion of the investigation, it was determined that the expected standards of safety procedures were not followed. The Transportation Aide/Driver #1 stated that when she exited the building after taking Resident #2 into the building that she entered the open door on the side of the van, not remembering that she had not put the lift back up into the receiving position. She said that because of her posturing in front of the resident to release the safety devices, she could not see that the lift was not in place. As she rolled Resident #1 backwards toward the lift, she was in a bent forward position and again, could not see that the lift was not in proper position. The Transportation Aide/Driver #1 is no longer employed at the facility. The 1 other facility van driver, Transportation Aide/Driver #2 was provided education regarding the use of the facility van and the proper use of the lift, utilizing the manufacturer's lift instructions, to include safe practice provided by the Executive Director on October 25, 2024. The Executive Director also completed a competency training with Transportation Aide/Driver #2. This was followed by an evaluation of her knowledge of the training which was conducted through observation utilizing the competency checklist by the Executive Director. This education and competency will be completed for all newly hired Transportation Aides/Drivers prior to being allowed to use the facility van or lift by the Executive Director, the Director of Nursing, or the Assistant Director of Nursing. All facility van transportation will have another staff member riding along and observing all on and off loading of the residents going to outside appointments on the van for 90 days starting on the afternoon of October 28, 2024. The observer is a patient care assistant (PCA) assigned to go on outside appointments as needed to ensure the safety of the residents. The PCA was educated by the Executive Director on October 25, 2024. Any further observers will receive the training by the Executive Director prior to riding on the transportation van. This education included what to observe while onloading and offloading of residents. This included safe transferring from van to lift (offloading) and from the lift to the van (onloading). The observer was also made aware to inform the Transportation Aide/Driver of any unsafe practice so it could be immediately corrected or intervene if necessary to ensure resident safety. If the unsafe practice was not immediately corrected, the PCA was educated to call the Executive Director immediately. All residents who had outside appointments were taken by outside transport vendors during the time when the facility van was not in service, October 24, 2024, through October 28, 2024. The outside transport companies were contacted by the Executive Director to confirm that their drivers/transportation aides were properly trained on how to onload and offload residents safely on their van. Outside transport vendors provided proof of education about onloading and offloading residents while using the lift prior to transportation services to ensure the safety of the residents. The van lift was inspected on October 28, 2024, by an authorized lift service station, and the lift was deemed safe for use. The van was ready for routine operation after it was inspected on the morning of October 28, 2024, and began providing service to our residents on the afternoon of October 28, 2024. Transportation Aide/Driver #2 is currently utilizing the facility van to transfer residents to and from appointments and there have been no wheelchair van related incidents. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Quality monitoring will be performed by the Executive Director, or a nurse manager, Director of Nursing, or Unit Manager, in the absence of the Executive Director. This will be conducted on 2 different residents weekly that are being loaded and unloaded by the transportation aides/drivers, to ensure residents are safely loaded and unloaded from facility van prior to transporting to and from appointments per manufacturer's instructions for 12 weeks and then monthly for 3 months. Any observed unsafe practices will be drawn to the attention of the Transportation Aide/Driver for correction. In the case of any unsafe practice, the Transportation Aide/Driver will be re-educated, that will include a competency at the conclusion of the education. The facility made the decision to monitor/audit and bring this to Quality Assurance (QA) on October 24, 2024, to include review of the Quality Monitoring. 5. Include dates when corrective action will be completed. The facility's corrective action plan was validated by the following: The facility provided documentation of Transportation Aide/Driver #2 web-based training courses on driving basics, defensive driving, and a checklist that included return demonstrations on how to load and upload residents from the transportation van. The facility provided documentation of van service records provided by an outside company which validated the lift was working properly following the incident, along with evidence of their audits as outlined in their plan of correction. Their audits included observation of Transportation Aide/Driver #2 to ensure she continues to follow lift and van safety instructions regarding boarding safety, patient securement, and patient assistance, including Resident #1. Daily monitoring of all residents using the transport van lift was being conducted and that information was presented in the facility's weekly QA meetings. On 12/11/24 at 2:19 PM Transportation Aide/Driver #2 was observed loading and unloading Resident #5 from the facility van using the lift. Transportation Aide/Driver #2 explained in detail the steps she takes and the safety measures she followed when using the lift as she was loading and unloading Resident #5. An interview conducted with a resident who had been recently transported to an appointment revealed he had no concerns with being loaded or unloaded from the van, being secured safely in the van, and felt the transport was safe. Transportation Aide/Driver #2 stated she completed the refresher course as part of the facility plan of correction on 10/24/24 following the incident. Transportation Aide/Driver #2 provided documentation showing she was cleared to transport residents using the lift. The facility's implementation for corrective action plan with a date of compliance of 10/29/24 was validated on 12/11/24. The IJ removal date was 10/29/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews and a life safety surveyor interview the facility failed to ensure the safety of residents in the designated smoking area of the facility when a staff member supervising the residents who smoked lit Resident #78's cigarette and allowed the resident to smoke with a combustible tank of compressed oxygen attached to the back of her wheelchair while she sat in the wheelchair. Residents who were also smoking were seated near the oxygen tank. The oxygen tank was turned off while the residents smoked. Even if turned off, it is not safe to smoke around an oxygen tank, oxygen-enriched levels can remain on tubing, clothing, hair, and skin increasing the risk for fire and/or explosion. Supplemental oxygen can make fires burn faster and hotter. This practice was for 1 of 8 sampled residents but placed 7 additional residents at risk for the high likelihood of serious injury or harm. Immediate jeopardy began on 6/26/24 when a staff member lit Resident #78's cigarette with an oxygen tank attached to her wheelchair. The immediate jeopardy was removed on 06/27/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: Resident #78 was readmitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease. Review of Resident #78's physician's orders dated 04/10/24 included an order for continuous oxygen at 3.5 liters via nasal canula. Resident #78's smoking evaluation dated 04/10/24 revealed the Resident was a smoker and was able to communicate why oxygen must always be shut off prior to lighting cigarettes. Resident #78 was not able to light cigarettes safely with a lighter. Resident #78 was marked as smokes safely (Does not allow ashes or lit material to fall while smoking, inhaling or holding smoking item. Remains alert and aware while smoking. Does not forget he/she is smoking or falls asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated area). The summary of the evaluation revealed resident was marked as required supervision while smoking. Review of Resident #78's admission Minimum Data Set (MDS) dated [DATE] revealed she had moderate cognitive impairment and was on oxygen therapy. The Current Tobacco Use section was marked No. Review of Resident #78's care plan dated 04/17/24 revealed a focused area for smoking and interventions included the Resident would not smoke with oxygen tank attached to wheelchair. On 06/26/24 at 9:15 AM an observation of residents in the designated smoking area, from the vending room exit door, revealed Resident #78 sitting in a wheelchair, smoking a lit cigarette and had a portable oxygen tank attached to the back of her wheelchair. Her nasal canula tubing was draped over the back of the wheelchair. There were 7 other residents smoking in the smoking area along with 5 staff. The 5 staff in the smoking area included the Maintenance Director, the Human Resources Coordinator, the Central Supply/Scheduler, and 2 contract housekeepers. This surveyor went to the Director of Nursing (DON) and asked her to observe the residents in the smoking area. There was no designated area for oxygen tank storage at the exit door. On 06/26/24 at 9:22 AM an observation was conducted of the designated smoking area with the DON. The DON stated, Oh no and went to the smoking area and removed the oxygen tank from the sleeve on the back on Resident #78's wheelchair. The DON stated the oxygen tank should have been removed from the wheelchair prior to exiting the building to go to smoke. The DON did not indicate why the oxygen tank should not be attached to the resident's wheelchair while she smoked. An interview was conducted with the Maintenance Director 06/26/24 at 10:15 AM and he stated he monitored the 2:00 PM smoke break. He stated one of the Nurse Aides (NA) usually escorted the residents to the smoking area. He stated all the residents were already outside when he got to the smoking area. He was unable to specifically recall the exact time he arrived in the smoking area. The Maintenance Director recalled he had opened the door for the residents to exit to the smoking area before he went to get the cigarette box containing the residents' smoking materials. He stated the Scheduler/Central Supply staff, Housekeeper #3, and the Human Resources Coordinator were already in the designated smoking area. He stated after opening the door for the residents to exit, he went to the nursing station to retrieve the residents' smoking materials. The Maintenance Director explained he took the cigarettes out to the smoking area. He said he lit all the residents' cigarettes because they were not allowed to keep smoking materials with them. He stated on 06/26/24 during the 9:00 AM smoke break, he lit Resident #78's cigarette. He said he did not notice the portable oxygen tank on the back of her wheelchair. He stated he had not received any education related to smoking and oxygen tanks. He further stated he knew oxygen was flammable and could explode. He said there were no signs warning against oxygen use in the smoking area. He stated, when the DON removed the oxygen tank from her wheelchair, Resident #78 told him the nurse had told her she could go to the smoking area with her portable oxygen tank if it was set on zero (0). The Maintenance Director stated the NAs usually removed the oxygen tanks prior to escorting the resident outside to smoke. He stated he did not know where the NAs stored the tanks when they removed them from the residents' wheelchairs. He stated he had no instructions in his office and no books containing instructions for storing portable oxygen. On 06/26/24 at 11:15 AM an observation and follow-up interview were conducted with the Maintenance Director. During the observation, measurements were obtained to show the proximity of the tank to the facility and to the resident for the risk of fire. The Maintenance Director measured from the vending room exit door to the location where Resident #78 was positioned in the designated smoking area. The measurements revealed Resident #78 was sitting 67 feet from the vending room exit door and 4 feet from other residents on each side of her wheelchair. There was a fire extinguisher with a full charge on one post and a fire blanket located in a metal box on another post. There were two Designated Smoking Area signs. There were no signs to warn against having oxygen in the designated smoking area. An interview was conducted with Resident #78 on 06/26/24 at 11:45 AM and she stated her portable oxygen tank was off when she went to the designated smoking area at 9:00 AM. She stated she had been going outside with her portable oxygen tank attached to the back of her wheelchair for the last month. She stated she had been in the facility for three months and had started smoking regularly one month ago. She stated no one had ever told her she could not go outside with her portable oxygen tank attached to the back of her wheelchair until the DON removed her portable oxygen that morning (6/26/24). Resident #78 stated she transfers herself to her wheelchair and propels her wheelchair herself to the smoking area. The Resident stated prior to 06/26/24, Unit Manager #3 had gone out to the smoking area when Resident #78 had her portable oxygen tank on her wheelchair. She stated Unit Manager #3 told her it was okay to go outside to smoke with the portable oxygen tank on her chair as long as it was off. She stated she goes outside once in the morning and once in the evening. On 06/26/24 at 1:45 PM a follow up interview with Resident #78 was conducted and she stated she turned off her oxygen tank before she went to smoke. She stated she stopped at the nursing station on her way to the smoking area for the 9:00 AM smoke break, she got out of her wheelchair, turned off her oxygen, got back in the wheelchair and wheeled herself down the hall to the smoking area. She stated she did not recall if there was a nurse or other staff at the nursing station when she stopped there. On 06/26/24 at 3:35 PM during an observation Resident #78 demonstrated her ability to transfer from her bed to her wheelchair and from her wheelchair she stood and walked to the back of her wheelchair. She demonstrated she could turn her portable oxygen tank setting from 0 to 3 on the tank stationed in the portable tank holder on her wheelchair. Resident #78 stated she never removed or had staff remove her oxygen tank prior to going to the smoking area to smoke. She stated she always had her oxygen tank attached to her wheelchair when she went to smoke. On 06/26/24 at 12:15 PM an interview was conducted with NA #3 stated Resident #78 got up on her own every morning, transferred herself to her wheelchair, and transported herself to the smoking area. NA #3 stated Resident #78 was very independent and did not wait for staff to assist her with transfers or escort her to the smoking area. NA #3 stated she did not adjust the setting on Resident #78's portable oxygen tank. She stated Resident #78 adjusted the settings on her oxygen tank on her own. An interview was conducted on 06/26/24 at 12:20 pm with Unit Manager #3. She stated she had smoked with Resident #3 in the past. She stated she did not go to Resident #78's room and talk to her on the morning of 06/26/24. She stated Resident #78 had started going out to smoke 1 month ago after being in the facility for about 3 months. Unit Manager #3 stated she stocked the cigarette box and knew Resident #78 did not smoke much. Unit Manager #3 stated Resident #78 may have asked her to turn off her portable oxygen tank prior to going to smoke but she did not know Resident #78 was going to smoke. Unit Manager #3 stated she probably assumed Resident #78 was going back to her room. Unit Manager stated Resident #78's oxygen order was for continuous oxygen. Unit Manager #3 stated she was not sure where Resident #78 went after she turned the oxygen off. Unit Manager #3 stated she should not have turned off Resident #78's oxygen when she did not know where the Resident went after she turned the oxygen off. She stated Resident #78 could have gone to smoke or could have gone to her room; she did not know which. Unit Manager #3 stated that it was Resident #78's right to request the oxygen be turned off. On 06/26/24 at 12:55 PM an interview was conducted with Housekeeper #3. She stated at times she went to the designated smoking area to smoke while on her break while the residents were smoking. She stated she worked for a housekeeping agency and did not monitor residents. She stated she did not assist residents outside to the smoking area because it was not part of her job duties. She said she did not notice whether Resident #78 had a portable oxygen tank on her wheelchair that morning. She added she had not received training or education that pertained to smoking or oxygen tanks. An interview was conducted on 06/26/24 at 1:10 PM with the Central Supply/Scheduler and she stated she was in the smoking area 5 minutes prior to residents' arrival to the area. Central Supply/Scheduler stated from where she was positioned in the smoking area, she did not see the portable oxygen tank on back of Resident #78's wheelchair on 06/26/24. She stated she had never changed the setting on Resident #78's oxygen tank. She stated if asked, she would take a resident's oxygen tank to their room and put it in portable holder. She stated she received oxygen tank training during orientation and yearly through an online training program. She stated the training included the dangers of oxygen, flammables, and smoking. She added if she had noticed the oxygen tank on the back of Resident #78's wheelchair, she would have removed the tank from the smoking area due to the danger. On 06/26/24 at 1:25 PM an interview was conducted with Housekeeper #2. She stated she was not responsible for monitoring residents. She further stated she did not assist in escorting residents to the smoking area because it is 'not in her scope'. She said she had never paid attention to or noticed an oxygen tank on Resident #78's wheelchair. She stated that although she had not received training that pertained to smoking or oxygen use, she knew it could cause an explosion. An interview was conducted with the Human Resources Coordinator on 06/26/24 at 1:30PM and she stated she assisted with smoke breaks at times. She stated she assisted with monitoring the 9:00 AM smoke break on the morning of 06/26/24. The Human Resources Coordinator said she was already outside when the residents exited the building to smoking area. She stated she did not notice the oxygen tank on Resident #78's wheelchair. She stated she had never witnessed the Resident #78 with an oxygen tank on her wheelchair. She said if she had observed the oxygen tank on the back of the wheelchair, she would have removed the tank and she would have asked the Central Supply/Scheduler what to do with the tank. She stated she knew an oxygen tank was not supposed to go outside. On 06/26/24 at 2:30 PM a phone interview was conducted with the NC DHHS Life Safety Surveyor, and he stated that smoking and/or an open flame in the vicinity of a compressed oxygen cylinder is a fire hazard. He further stated it did not matter if the oxygen tank was off, it still posed a risk of fire and/or explosion. An interview was conducted on 06/26/24 at 5:15 PM with the Administrator and DON. The Administrator stated Resident #78's oxygen tank should not have been in the smoking area. She stated it was not the Maintenance Director's designated job duty to monitor the residents while they smoked. She stated the staff in the smoking area were responsible for monitoring the residents while they smoked. The DON stated she the daily assignment sheets included the NAs' names assigned to smoke breaks on each shift. The DON stated the Maintenance Director often offered to monitor the smoke breaks when the assigned NA was busy. The DON stated on weekends the assigned NA monitored the smoke breaks. She stated the smoke break assignment was subject to change to meet the facility needs. The Administrator stated the smoke break assignment falls under the Other duties as assigned description. The DON stated training related to smoking and oxygen use was provided for facility staff during orientation and yearly but was not provided to housekeeping, dietary, and therapy. The Administrator stated all staff were responsible for residents' safety while on the facility grounds. She stated that included break time if the staff were in the smoking area while residents were there smoking. She stated staff should have made sure Resident #78 did not enter the designated smoking area with her portable oxygen tank attached to her wheelchair because she was aware that oxygen was flammable and smoking near a tank whether it was turned on or off could potentially explode and harm residents. The Administrator was notified of immediate jeopardy on 06/26/24 at 6:36 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as result of the noncompliance; and 1. The corrective action for alleged deficient practice was accomplished by: Prior to the incident, Resident # 78 was in her bed, utilizing the Oxygen concentrator in her room. Resident #78 self-transferred into her wheelchair with a portable oxygen tank that was turned off, on the back of her wheelchair. The resident attached the end of the tubing to the portable oxygen tank and placed the nasal canula tubing in the bag on the wheelchair. The oxygen was not turned on and the nasal canula was not applied. Resident self-propelled into smoking area while Maintenance Director held the door for her and other residents as they were entering the courtyard to smoke. The resident was observed smoking in the courtyard with a portable oxygen tank attached to her wheelchair by the surveyor. The surveyor observed the tank on the back of the wheelchair while the resident was in the courtyard smoking, the surveyor left the courtyard observation to notify the Director of Nursing (DON) who was in her office that she had a concern in the courtyard and asked her to walk to the courtyard. When the DON arrived at the door that enters the courtyard, the surveyor asked the DON if she saw anything wrong. The Director of Nursing immediately went to the courtyard and removed the oxygen tank from the back of resident #78's wheelchair on 06/26/2024. The surveyor observed 4 staff members, the Maintenance Director, the Human Resources Director and 2 housekeepers, in the designated smoking area while the resident was smoking with a portable oxygen tank on the back of her wheelchair. Immediately after the Director of Nursing removed the tank from the resident's wheelchair and placed the tank in the secured portable holder in residents #78's room, the Director of Nursing assessed the smoking area through observation for safety signage as it related to no smoking with oxygen and identified there was no signage regarding no oxygen in smoking area. The only sign posted was Designated Smoking Area. The Maintenance Director, Human Resources Director nor the 2 housekeepers were educated or trained on the importance of monitoring for the use of oxygen. None of the staff in the designated smoking area noticed the oxygen tank on the back of the wheelchair. Resident #78 was assessed for smoking on 4/11/24. The assessment identified the resident required supervision due to the inability to safely light a cigarette with a lighter. The maintenance director was assigned to supervise the smoke break at 9 am and failed to notice and remove the oxygen tank on the back of the wheelchair on resident #78 on 6/26/24. The Director of Nursing and Unit Manager identified residents with oxygen use through active physician orders on 06/26/2024. The list of these residents was provided to the social worker who educated the residents that oxygen / oxygen tanks are prohibited in or around the designated smoking area on 06/26/2024 and documented education provided in the residents' chart. The Director of Nursing and Unit Manager identified residents that smoke through smoking assessments on 06/26/2024 and this was verified against the list of current smokers. The list of residents was provided to the social worker who educated the identified residents on ensuring oxygen tanks were to be removed from the wheelchair before entering the smoking area on 06/26/2024 and documented education provided in the resident's chart. Specify the action the entity will take to alter the process or system failure to prevent serious adverse outcome from occurring or recurring, and when the action will be complete. The Director of Nursing educated the Maintenance Director on ensuring oxygen is removed from the wheelchair prior to entering smoking area and the dangers of smoking around oxygen, which is combustible and could cause a fire and/or burns on 06/26/2024. The Unit Manager placed an oxygen rack next to the exit to the courtyard, in the vending machine room, for the oxygen tanks to be placed in before exiting the building, on 06/26/2024. 100% of facility staff to include contract staff were educated by the Director of Nursing and Unit Manager on removing oxygen tanks and placing portable oxygen tanks in the secure oxygen rack prior to residents entering the courtyard smoking area on 06/26/2024. The Director of Nursing re-educated licensed nurses, certified nursing assistants, non-direct staff, contracted staff that includes therapy, housekeeping and dietary staff on the smoking policy, which includes oxygen is not permitted in the designated smoking area, and ensuring oxygen tanks are removed from the wheelchair and or ambulatory residents before entering the smoking area due to the dangers of smoking around oxygen on 06/26/2024. The Executive Director placed signs on the door entering the smoking area as a reminder to ensure oxygen tanks removed from the wheelchair and placed in oxygen rack before entering smoking area as well as signs that state NO OXYGEN OR OXYGEN TANKS BEYOND THIS POINT on 06/26/2024. The Executive Director placed NO OXYGEN / NO OXYGEN TANKS signs in the designated smoking area on 06/26/2024. The Director of Nursing and Unit Manager completed Skilled Check Off Competency for Smoking Safety in accordance with policies and procedures for oxygen safety precautions for oxygen use and not smoking around oxygen, for Licensed nurses, certified nursing assistants, department managers, receptionist, maintenance assistant and activity assistant; these are the staff members that are allowed to supervise smokers. These individuals listed have completed the skills check off competency includes smoking times, where to obtain smoking materials, oxygen tank removal, apron use, the location of fire blankets, fire extinguishers, and where to obtain the list of unsafe smokers on 06/26/2024. The daily assignment sheets identify who is assigned to supervise the smokers and the daily assignment sheets are posted at both nurse's stations. If the assignments are changed, the nurse is responsible to communicate that to the newly assigned personnel. The skilled check off sheet that identifies the responsibilities for supervising the smokers is in notebooks placed in the vending machine room near the entrance to the designated smoking area and at each nurse's station. The responsibilities of the supervisor of the smokers are: o To know where smoke times are posted, at exit to courtyard o To obtain smoking materials from the South Hall Medication Cart o Assists residents to smoke area as needed o Removes any Oxygen tank and places in designated storage area in vending room (ask nurse for assistance in turning off oxygen as needed) o Prior to beginning smoke breaks, ensures that there is no oxygen or oxygen tanks anywhere in the courtyard o Utilizes smoking aprons from the designated smoking area located in the grey bin o Sanitize hands o Passes out cigarettes to each resident o Lights each resident's cigarette o Faces the residents smoking and continuously monitor their safety o Knows location of fire extinguisher o Knows location of fire blanket o Assists the residents back in the building after smoke break o Replaces any oxygen tanks from storage to the resident (ask nurse to turn on oxygen if needed) o Knows to return smoking materials to designated South Hall Medication Cart An ADHOC Quality Assurance Performance Improvement Committee was held on 06/26/2024 to formulate and approve a plan of correction for the deficient practice. Date of Immediate Jeopardy Removal 6/27/24. The title of the person responsible for implementing the acceptable credible allegation for immediate jeopardy removal. The Administrator is responsible for the credible allegation of immediate jeopardy removal. Alleged date of IJ removal 06/27/24. A validation of immediate jeopardy removal was conducted on 06/27/24 as evidenced by the following verification of education for licensed nurses, certified nursing assistants, non-direct care staff, contracted staff that included therapy, housekeeping, and dietary staff on the smoking policy, which included oxygen is not permitted in the designated smoking area, and ensuring oxygen tanks are removed from the wheelchair and or ambulatory residents before entering the smoking area. Observation revealed a tank holder in the vending area next to the exit door leading to the smoking area. The exit door had a sign that read No Oxygen or Oxygen Tanks Beyond This Point and signs in the smoking area that read No Oxygen/No Oxygen Tanks. The IJ removal date of 6/27/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, family, staff, Psychiatric Nurse Practitioner and Law Enforcement interviews the facility failed to protect a resident's right to be free from physical abuse when Nurse Aide (NA) #1 and NA #2 forcefully turned Resident #1 causing her forehead and left knee to hit the wall. The two NAs continued to provide incontinence care after the resident yelled and screamed for them to stop. Resident #1 reported she no longer felt safe when new staff came in to provide care to her. One of three sampled residents were affected by the deficient practice (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. The Resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. She was admitted with diagnoses that included acute cystitis, unspecified dementia without behavioral disturbances, fibromyalgia, lack of coordination, muscle weakness, chronic pain syndrome and osteoarthritis. Resident #1's care plan dated 09/03/23 revealed no focused area, goals, or interventions for behaviors such as resistance to care or physical or verbal aggression. The care plan included the focused area of care for an activities of daily living self-care performance deficit with interventions to include the Resident required extensive to total assistance by 1-2 staff for toileting needs. No intervention for brief size or color preference was noted. A review of the physician's orders dated 11/28/23 revealed when Resident #1 returned from a stay in the hospital on [DATE] she was prescribed the blood thinner, Apixaban 5 milligrams 1 tablet daily, for deep vein thrombosis prevention. Resident #1's skin assessment dated [DATE] revealed a body chart marked with greenish bruising to the left antecubital area (front of the elbow), purple bruising on the left knee, yellow bruising on her ankle, purple bruising on both wrists, yellow bruising on left forearm, and greenish/yellow bruising to back of upper right arm. Also noted were small, open areas on each buttock. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact. She required substantial/maximal assistance for bed mobility, toileting, and personal hygiene. The assessment indicated Resident #1 was frequently incontinent of bowel and bladder. The assessment further indicated Resident #1 had no behaviors such as resistive to care or physical or verbal aggression, hallucinations, or delusions. On 12/07/23 at 7:45 AM an interview with Resident #1 revealed on 12/01/23 at approximately 11:30 PM, NA #1 and NA #2 entered her room to provide incontinence care after she pressed her call bell. She stated she needed to be changed because she had been incontinent of urine only. She stated she did not have a bowel movement. She stated the NAs brought a yellow brief (extra-large) with them and Resident #1 informed them she wore blue briefs (large). She stated she told them her blue briefs were in her top drawer, but they refused to get one from the drawer. She stated the NAs said they were not going to look in her drawer. Resident #1 stated NA #1 said, You will wear what I want you to wear. She said she told the NAs to just leave her wet and go on their way. They refused, saying they could not leave her wet and insisted she be changed. Resident #1 stated NA #1 was positioned at her legs and NA #2 was positioned at her shoulders. NA #2 proceeded to forcefully turn her in the bed, causing her head and left knee to hit the wall. She stated she yelled and screamed for them to stop because she did not want to wear the yellow brief and they were hurting her. Resident #1 stated they would not stop when she asked. She stated she kept screaming and yelling for them to stop. Resident #1 stated they finally rolled her back over and forcefully pulled the brief up between her legs. They turned off the light, left and closed the door. Resident #1 stated she called her family member and told her what happened, and her family member called the Administrator and informed her of the incident. She further stated she doesn't feel safe anymore when new staff come in to provide care to her. She stated incontinence care for her was usually provided by only one NA. An observation on 12/07/23 at 7:45 AM of the room revealed Resident #1's bed was on the right side of the room, lengthwise along the wall, with the head of the bed at the doorway entrance. A curtain separated the beds of Resident #1 and Resident #2. Resident #2's bed was 3-4 feet crosswise with the head of her bed at a 90° angle to the foot of and approximately 3- 4 feet away from the foot of Resident #1's bed. In a follow-up interview with Resident #1 on 12/07/23 at 1:10 PM she stated she did not recall a third NA being in the room. She stated she never heard anyone mention NA #3's name while they were in her room. Resident #1 became tearful and stated while in therapy the Social Worker (SW) and another administrative person came to the therapy room and said they wanted to measure her to see if her brief fit her correctly. She stated they informed her none of this would have happened if she had been wearing the right brief. Resident #1 said she knew they meant to put her in yellow briefs even though she said she explained to them she doesn't like the yellow briefs because they bunched up between her legs, they were bulky, and they allowed urine to leak through. On 12/07/23 at 5:50 PM during a phone interview with NA #1 she revealed she was in the hallway charting at the kiosk when NA #2 went to answer a call light for Resident #1. She stated NA #2 came and got her to assist her to turn the Resident with the draw pad. She stated the Resident requested a certain brief they were out of at the time. NA #1 stated she told her they were out of that color. NA #1 added she told Resident #1 they needed to change her because she had had a bowel movement. NA #1 stated they provided incontinence care and put a yellow brief on the Resident. NA #1 explained they slid the yellow brief under Resident #1 and left the room to get the nurse because the Resident was screaming loudly. NA #1 stated she was in Resident #1's room with NA #2 and NA #3. The nurse aide stated the resident was just screaming, she did not say any words just made sounds. NA #1 stated they continued to put the yellow brief on Resident #1 after Resident # 1 told her to stop because she could not leave her in a soiled brief. On 12/07/23 at 5:38 PM a phone interview was conducted with NA #2. NA #2 stated Resident #1 rang her call bell and she went into the room to change her. She stated Resident #2 was out of blue briefs. She stated she told the Resident and that the blue briefs were too small. She stated she told the resident she would have to use a yellow brief. NA #2 stated when she turned Resident #1 over with the draw pad the Resident started screaming. NA #2 stated they cleaned Resident #1 up quickly and left the room. NA #2 stated Resident #1 kept screaming about the yellow brief. NA #2 added Resident #1 screamed Stop, I don't want the yellow brief. NA #2 stated at that point she stopped and went in the hallway to get NA #1 because they usually worked together. She stated NA #3 was in the room with her when she went to get NA #1. She stated NA #3 was there to observe. NA #2 explained she was at Resident #1's shoulder and NA #1 came and helped turn the Resident over to change her. NA #2 said the resident didn't refuse to be changed, it was just all about the brief. NA #2 stated they continued to put the yellow brief on Resident #1 after Resident #1 told her to stop because she could not leave her in a soiled brief. On 12/07/23 at 6:01 PM a phone interview was conducted with NA #3, and she stated NA #1 asked her for assistance to provide incontinence care to Resident #1. She stated she was in the room with NA #1 and NA #2. NA #3 stated when she got in the room, NA #1 and NA #2 were cleaning the Resident. She stated the Resident was fussing about the brief. NA #3 stated the Resident said she always wore a blue brief not the yellow ones. NA #3 stated Resident #1 was screaming Leave me alone and kept screaming she only wore blue briefs. She stated she tried to calm and comfort Resident #1. After the incident, NA #3 stated she went back in Resident #1's room and offered to change her into a blue brief. She stated the Resident declined because she was still upset. She offered to change her from the yellow brief to the blue brief because she saw how much it had upset the resident. NA #3 said when she went back later, and the Resident did allow her to change her to a blue brief. When asked why she didn't intervene, NA #3 stated she planned to go back to Resident #1 after NA #1 and NA #2 left to put a blue brief on her and help her calm down. On 12/07/23 at 9:18 AM an interview was conducted with Resident #1's roommate (Resident # 2). Resident #2 was cognitively intact. Resident #2 stated two NAs had a yellow brief with them when they came into the room and pulled the curtain. Resident #1 told them she didn't wear a yellow brief; she wore blue ones. Resident #2 stated one of the NAs said something to the effect of you are going to wear these ones now. She stated she heard Resident #1 screaming, No. Resident #2 said she could see between the curtain and the wall and saw the NAs slam Resident #1 into the wall roughly. She stated that was all she could see but she heard Resident #1 screaming a lot. Resident #2 said she went to the door and called out for help for Resident #1. Resident #2 added the two NAs came and stood at the door laughing and listening to the conversation between Nurse #1 and Resident #1. Resident #2 stated she had never witnessed any NAs behave in such a manner in the two years she had been a resident in the facility. She said she had not seen anyone as rude or hateful as the two NAs. Resident #2 stated to her knowledge there were only two NAs, NA #1, and NA #2, in the room providing care to Resident #1. On 12/08/23 at 9:40 AM a telephone interview was conducted with Resident #1's Family Member who was her Responsible Person (RP). The Family Member stated her mother called her on Friday night, 12/01/23 at 11:22 PM. She stated her mother's exact words were, [NA #1 and NA#2] manhandled me. She stated they made her hit her head on the wall. She stated her mother told her she yelled for help, and no one came to help her. She stated her mother said NA #1 and NA #2 told her she was going to do as they said. The Family Member stated her mother said she told them no and she asked them to stop. The Family Member said her mother said NA #1 and NA #2 insisted she put on a yellow brief. The Family Member stated her mother always wore a blue brief until this occurred. She said NA #1 and NA #2 put the yellow brief on her and didn't tape the brief on, turned off the light, left the room, and closed the door. The Family Member stated she called the Administrator on her cell phone. The Family Member stated she told the Administrator what had happened and didn't want NA #1 and NA #2 back in her mother's room. The Family Member stated she told the Administrator exactly what her mother said that NA #1 and NA #2 had manhandled her and put a yellow diaper on her and pushed her head against the wall. The Family Member stated she had not talked to the Administrator again until 12/07/23, when the Administrator called her with the Director of Nursing [DON] on the line with her. She stated the Administrator apologized for not communicating sooner with her. The Family Member stated the Administrator told her that she knew exactly how things happened because there were three NAs in the room not two. The Family Member stated that the Administrator told her there was another NA in the Resident's room who saw and heard everything. The Family Member stated, so now my Mama is the one who is combative, and all her bruises are from the hospital. The Family Member stated that she told the Administrator and DON it was hard to believe there were three NAs in her mother's room because she could hardly ever even get one in there when she pressed her call bell. The Family Member stated this was the first time she had ever received a report that her mother was combative with staff. She stated she had never reviewed a care plan which included a plan for combative behavior. The Family Member stated her mother told her she was measured in therapy yesterday, 12/07/23, to determine her brief size. The Family Member stated her mother told her the Social Worker (SW) and another staff told her none of this would have happened if she had been wearing the right brief. She stated the SW called her on 12/07/23 and told her she needed to talk to her mother (Resident #1) about wearing a yellow brief. The Family Member stated the SW worker said her mother had it in her head that she needed the blue brief. The Family Member stated her mother preferred the blue brief because it didn't bunch up between her legs and it did not leak. The Family Member stated she felt it should be her mother's choice. She stated her mother had never been combative. The Family Member stated when she visited her mother on 12/02/23 at about 7:00 AM the day shift nurse, Nurse #3, told her she called the police and reported the incident. The Family Member stated Nurse #3 said the events from the previous night on 12/01/23 had not been reported to her. The Family Member said she asked Nurse #3 to help roll Resident #1 over so she could look at her and she herself took pictures of her mother's bruises. A phone interview with Nurse #1 on 12/08/23 at 10:16 AM. Nurse #1 stated, on Friday 12/01/23, NA #1 and NA #2 came to her and told her Resident #1 was upset. She stated she went to assess the resident and Resident #1 told her she was upset and angry because the NAs had put a yellow brief on her instead of a blue brief. Nurse #1 stated the Resident was irritated and didn't want NA #1 and NA #2 back in her room. She stated she told the resident she was sorry they upset her and didn't do as she requested. Nurse #1 stated she told the Resident she would talk to them about it and switch their assignments, and they should never come in her room again. She stated she did not observe any bruises or red marks when she assessed the Resident. She stated the Resident said she told the NAs not to put a yellow brief on her, but they did it anyway. Nurse #1 said she asked Resident #1 if she was okay and the Resident said she was mad about the brief. Nurse #1 stated she reassigned NA #1 and NA #2 to another hall. Nurse #1 stated she told NA #3 to change the resident to a blue brief the next time the resident needed changed. She stated NA #3 went back in later and offered to change the resident, but she declined because she was still upset. Nurse #1 stated the Resident never said anything about the NAs being rough or abusive. Nurse #1 stated she checked on the Resident hourly throughout the night and the Resident slept without any issues. She stated the Resident eventually did allow NA #3 to change her during the next rounds. A phone witness statement was given by Nurse #1 to the DON on 12/07/23, untimed. The statement related to the accusation of abuse that was reported on December 2, 2023. The statement read, NA #1 and NA #2 told her Resident #1 was mad because they had put a yellow brief on her instead of a blue brief. The statement revealed Nurse #1 asked if Resident #1 was okay and the NAs told her Yes. Nurse #1 told the NAs she had changed their assignment and Resident #1 was ok with the change. She said she then asked Resident #2 if she had heard or seen anything, and Resident #2 stated I haven't heard or seen anything because my curtain was pulled. Nurse #1 stated in the phone statement NA #3 went into the room and offered to place a blue brief on Resident #1 and she stated, I'm ok, get out, I will be fine. Nurse #1 stated in her phone witness statement she checked on Resident #1 four more times, and she was asleep. The phone witness statement given by Nurse #1 to the Administrator on 12/07/23 at 8:00 PM revealed Nurse #1 stated she told Resident #1 the assignments had been changed and asked her if she was okay and she said, Yes, I am just mad. When Nurse #1 asked her why she was mad, she said, Because I told them that I wanted a blue brief and they put a yellow one on me. The phone statement revealed Nurse #1 asked Resident #1 if she would feel better if they changed her into a blue brief and she said, No, I am fine for now, but I am glad that they will not be back in my room. [NA #3] already offered to change me, I'm okay. Nurse #1 said Resident #1 told her she had talked to her family member and felt better. In her phone statement, Nurse #1 stated on her rounds during the night she went in Resident #1's room four times and she was sleeping. In a phone witness statement given by Nurse #1 to the Administrator and DON on 12/07/23 at 8:00 PM Nurse #1 stated on 12/01/23 between 11:50 PM and midnight, she was informed that Resident #1 did not want NA #1 and NA #2 to work with her, so the assignments were changed. She stated she went to Resident #1 to let her know the assignments were changed. She said, Resident #1 said, Good. A review of Nurse #3's witness statement written on 12/02/23 revealed Nurse #3 assessed Resident #1 during the morning medication pass. Resident #1 stated her left shoulder hurt because NA #1 and NA #2 had been extremely rough with her the previous night. Resident #1 told Nurse #3 the NAs forced the wrong brief on her and pushed her into the wall. Bruising was noted to the left kneecap and small round marks noted to left arm and wrist. Resident #1 stated she hit her head and shoulder against the wall. Nurse #3's statement revealed she notified the Resident's RP who directly called the Administrator. Nurse #3 stated she immediately contacted the Administrator who notified both the DON and the ADON. The witness statement revealed the County Sheriff's Department was also notified and they went to the facility and took statements. An interview was conducted on 12/08/23 at 10:55 AM with Nurse #3. Nurse #3 stated when she came in the morning of 12/02/23 she did not receive report of any concern from night shift regarding Resident #1. She stated when she went to give Resident #1 her medications and take vital signs, she noticed the Resident was upset and asked her what was wrong. Nurse #3 said the Resident told her two girl NAs were rough with her. She said the Resident told her the NAs put the wrong color brief on her. Nurse #3 stated the Resident said when they rolled her, they were very aggressive, and her head and knee hit the wall. Nurse #3 stated the Resident started pointing out bruises. She stated the Resident had several small bruises and discolorations on her forearms that were not phlebotomy or Intravenous (IV) sticks from the hospital. She stated these bruises were small, circular, dime-sized and she had a noticeable bruise on her inner left knee. Nurse #3 stated after she assessed Resident #1, she reported Resident #1's allegation to the Administrator. She stated the DON instructed her to call the police and report suspected abuse. She stated she called the police as instructed. She stated when the Assistant Director of Nursing [ADON] arrived she collaborated with her on the report. She stated the ADON notified the medical provider and completed the investigation. Nurse #3 stated the police arrived about the same time as the Resident's son and took everyone's info and took Resident #1's statement. Nurse #3 stated when the Resident's Family Member (RP) arrived she assessed her mother head-to-toe and took pictures. Nurse #3 stated she assisted the Family Member with assessing her mother and pointed out the small bruises on her arm and leg. Nurse #3 stated the bruises were there, but she did not imply to the Resident's Family Member how they got there. On 12/07/23 at 1:22 PM an interview was conducted with NA #5. She stated she was familiar with Resident #1. She further stated she was able to change her brief and provide care for Resident #1 by herself. She said she had never needed two or more people to care for Resident #1. She stated Resident #1 preferred the blue briefs. She added she could not recall a time when the resident was combative or refused care. In an interview with NA #4 on 12/07/23 at 1:25 PM she revealed she had worked at the facility for about one year. She stated she did not use two people to provide incontinence care for the Resident #1. She further stated she had never had to use three people with Resident #1. She said she had not observed Resident #1 refuse care or be combative. She stated Resident #1 used blue briefs. On 12/11/23 at 9:05 an interview was conducted with the County Detective in charge of Resident #1's case. He stated he was still in the process of investigating the allegation. He revealed the initial police report was filed on 12/02/23 and the investigation was ongoing. A late entry progress note entered by the ADON on 12/07/23 at 8:01 AM revealed she performed a skin assessment on Resident # 1 on 12/02/23 at 12:49 PM. The note revealed upon full body assessment, there was a small area of discoloration to the left knee. Three small areas of discoloration noted to the left forearm, very light yellow in color, and old in appearance. The progress note read the Resident pointed to an area on her right forehead and stated, that is where my head hit the wall. The progress note revealed upon inspection of the area, there was no raised area, redness, bruising, abrasions, or other evidence of recent trauma present. Scattered bruising to bilateral hands. The note added the Resident stated those bruises were from IV sites. Review of the witness statement written by the ADON on 12/02/23 revealed she was contacted by the Director of Nursing at approximately 11:30 AM regarding an incident reported by Resident #1. She obtained a statement from Resident #1 who had notified the day shift nurse of an issue with the night shift CNAs. After obtaining her statement, the ADON wrote that she completed a full body assessment to identify any skin issues. Her written assessment revealed there were scattered bruises noted to both hands. When questioned about the bruises, Resident #1 stated those bruises were from the IVs and needle sticks during her recent hospitalization. There was a half-dollar sized bruise noted to her right wrist. Resident #1 stated that bruise was also from an IV previously placed there. Resident #1 pointed out an area on right forehead and stated, this is where they slammed my head against the wall. The ADON wrote she was unable to identify any abnormalities to the area. There was no redness, bruising, swelling, raised areas, or other discoloration indicating any trauma. The written statement read Resident #1 then held up her left arm and stated, you can see the fingerprints here. The ADON statement read, upon inspection of area, there were three small areas of discoloration, very dull yellow in color and the areas appeared older in age. She wrote Resident #1 denied pain to area. The only other area noted was a small area of discoloration on the left knee. No other skin issues were identified. The ADON's written statement further revealed she observed no signs of recent trauma. In an interview on 12/07/23 at 4:00 PM with the ADON she revealed on 12/02/23 she took statements from NA #1, NA #2, NA #3, and Resident #1. When asked if she interviewed the Roommate, she stated no. The ADON stated Resident #1 told her that the roommate turned on the light and opened the door, but the ADON said the Roommate did not tell her she did so. The ADON said the roommate told her that the Resident was upset but that she did not see anything. The ADON stated that during her interview with Resident #1, the Roommate got back in bed and faced the wall like she did not want to get involved. The ADON revealed Resident #1 said she didn't want to get anyone in trouble, but NA #1 had been rough with her. The ADON stated the resident kept going on and on about the brief. She stated the NAs told her they had to use the yellow brief. The ADON said NA #2 said they explained to the resident that the blue briefs wouldn't fit her. The ADON said Resident #1 told her that NA #1 and NA #2 said she was going to have to do what they said do. The ADON stated Resident #1 told her the two nurse aides rolled her over and hit her knee against the wall and slammed her head against the wall. The ADON said she assessed Resident #1 and there was no trauma to her right forehead. The ADON said she did a full body audit and asked Resident #1 about the needlestick bruises. She said she saw discoloration on the left knee. The ADON stated the resident wanted her to check the bruises on her arm. The ADON said she observed very light yellowed old bruises. The ADON added the resident informed her that some of the bruises were caused by intravenous fluid administration and blood draws that were performed in the hospital. The ADON stated that NA #2 told her that she had worked with Resident #1 before, and she had been pleasant. The ADON stated that on 12/01/23 NA #2 said the resident was very agitated when she first went in the room. The ADON said NA #2 told the resident she was going to change her because the resident said she was wet. The ADON said NA #2 told her she went and got a yellow brief and when she returned Resident #1 became more agitated because NA #2 had a yellow brief in her hand. The ADON said NA #2 told her Resident #1 started yelling about wearing a blue brief not a yellow brief. NA #2 told the ADON that she explained to the Resident that the blue brief would not fit around her hips. The ADON stated NA #2 said the resident told her she was only a little wet and she didn't have to change her. At that time NA #2 explained to Resident #2 once they knew a resident was wet, they had to go ahead and change them to prevent skin breakdown. The ADON said NA #2 told her the Resident calmed down and became agreeable to being changed. The ADON said NA #2 told her she stepped out and went to get her NA #1 to help change Resident #1. The ADON said NA #2 told her when they got back to the room and started to change the Resident, she saw the yellow brief and started refusing again. The ADON said NA #2 said she saw the resident had had a large bowel movement. The ADON stated NA #2 said when the Resident looked back over her shoulder, she saw the yellow brief and began pushing against the wall to keep them from putting the yellow brief under her. The ADON stated that NA #2 told her that NA #3 was in the room and explained to the Resident that they were trying to get her clean and she needed to stop pushing against the wall. The ADON said the NAs told her they were not able to get Resident #1 completely clean, so they pulled the brief up but didn't attach the sides and left to give her time to calm down. An interview with the Director of Nursing (DON) was conducted on 12/07/23 at 12:44 PM. The DON stated she did not make assignment sheets for night shift. She stated when night shift staff arrived the nurse on the hall assigned them to a set of rooms on each hall. She stated on 12/01/23 NA #1 and NA #2 were assigned to the hall on which Resident #1 resided. She explained NA #3 was assigned to a different hall but had been asked by NA #1 and NA #2 to assist with incontinence care for Resident #1. On 12/07/23 at 1:30 PM an interview was conducted with the Psychiatric Mental Health Nurse Practitioner (PMHNP). The PMHNP stated he was familiar with the resident. He further stated he had not seen her since July when she went to the hospital. He stated when she came back from the hospital, she had not been picked up by him. He stated when he saw her today, he had come into the room to see her roommate. He said after speaking with Resident #1 he was going to reactivate her or pick her back up for services because she was upset and anxious during his conversation with her earlier in the day. In a second interview with the DON on 12/07/23 at 2:02 PM she stated when Resident #1 got upset, she became fixated on whatever upset her and would not let it go. She further stated the resident would continuously talk about whatever upset her and stayed worked up about small issues. She explained there were three NAs in the room the night of 12/01/23 because NA #1 was still orienting. The DON stated NA #1 was not a new NA, but she was slower about picking up on things and needed more guidance. She stated NA #1 worked with NA #2. The DON stated that NA #3 was assigned to another hall but was helping on that hall that night. The DON stated NA #1 and NA #3 had informed her when they turned Resident #1 over, she had feces on her. The DON stated NA #1 and NA #3 told her when the resident saw the yellow brief, she got mad and started swinging and became combative. She stated that the NAs told her they wanted to leave Resident #1 safe but had to get the feces off her. The DON explained NAs are trained to leave a resident when they are combative, but they had to leave her safe. In an interview on 12/07/23 at 3:43 PM with the Administrator and the DON, the Administrator revealed the incident occurred on 12/01/23 at approximately 11:20 PM to 11:30 PM. She stated Resident #1's Family Member called her and said she didn't want NA #1 and NA #2 in her mother's room because her mother was upset about the brief. The Administrator stated she called the DON at 11:40 PM and told her to move [NA #1 and NA #2] because they had put a yellow brief on the resident and that's not what the Resident preferred. The DON stated they moved NA #1 and NA #2 because they thought it would lessen Resident #1's anxiety so she could rest. The DON stated she tried to call Nurse #1's cell phone. Nurse #1 did not answer so Nurse #2 was called. Nurse #1 was the nurse assigned to Resident #1's hall. The DON stated when Nurse #2 went to Resident #1's room she heard the resident yell, Get out. When asked again why there were three NAs in the room, the DON stated NA #3 assisted NA #1 and NA #2 to turn the resident. When asked if it was necessary for three NAs to provide incontinence care for Resident #1, the DON stated sometimes. On 12/07/23 at 5:00 PM an interview was conducted with the Administrator. Present during the interview were the ADON, the DON, and the Admissions Coordinator. The Administrator stated she didn't think the NAs intentionally abused Resident #1, but they did violate her rights. The Administrator stated the NAs should have left the room when the Resident told them to leave her alone. The Administrator stated she would have explained to Resident #1 what was in her best interest and then she would have put the brief of her preference on her. The Administrator stated, as a nurse we know we always want what is in the best interest of the resident, but we must take into consideration their rights, wishes, and preferences. All staff mentioned above stated they agreed with the Administrator's statement that Resident #1's choice of brief color/size should have been honored and NA #1 and NA #2 should have left the room when Resident #1 told them to leave her alone. The Administrator was notified of immediate jeopardy on 12/08/23 at 4:45 PM. The facility provided the following corrective action plan with a completion date of 12/07/23. Immediate Action: NA #1 and NA #2 were suspended on 12/2/23. Resident #1 was immediately informed that NA #1 and NA #2 would no longer be working with her. Night shift RN on duty 12-2-23, emotionally assessed Resident #1 when informed that she was mad. Night shift RN checked on Res. #1 throughout the night. The RN Charge nurse completed a skin check on 12-2-23 @ 11:10 am. The Director of Nursing performed a skin check on 12-2-23 @ 11:45 am of Resident #1. These skin checks were compared to the readmission skin assessment performed by Unit Manager on 11/28/23 at 9:30 am Identification of other Residents: Skin sweeps were completed on all residents with a BIMS 8 or less by the Assistant Director of Nur[TRUNCATED]